Abdominal Pain in

Childhood
- an overview
Ms. Julie Galea MD MRCSEd
Paediatric Surgical Unit
Mater Dei Hospital
Malta
 Background
• Abdominal pain in childhood is common

• Most can be treated in the community

• Even those treated in a hospital setting

mostly recover without a diagnosis

• Disconcerting experience for most

clinicians
 Background
• Signs are often subtle and non
specific

• Children do not possess an adult’s

ability to explain what is wrong with
them

• Much has been written on the

subject – much controversy
 History
• Obtained from parents / guardians – they
know their child best!!
• Ask how the child’s behaviour compares to
normal
• Where possible involve the child
• Be sympathetic
• Take time to build rapport and interact
with them – history and examination must
be informal and playful – use concepts the
child understands
 History
• Birth / Perinatal history:
- Important to assess repercussions of
trauma/illnesses/congenital
abnormalities – eg preterm /
NEC / early UTIs
- Problems in pregnancy and
perinatally incl admission to NPICU
- Gestational age at delivery
- Mode of delivery
- Birth weight
- Location of birth (hereditary illnesses)
 History (cont)
• History of presenting complaint:
– Pain onset, duration, location, nature, radiation,
relieving and exacerbating factors (eg. Non specific abdo
pain is usually vague, central and colicky ; Appendicitis
is unilateral and well localised)
– Nausea and vomiting. Is vomiting bilious? – always
ominous in children
– Good appetite / Feeding well
– Irritability / Crying
– Passage of blood and mucus rectally/ with stool
– Bowel habit
– Dysuria / Urinary frequency
– Recent URTIs, GI upsets
– Wetting nappies / passing adequate/large amount of
urine
– Menstrual / sexual history in older girls
– Polydypsia
 Alarm symptoms
• Unintentional weight loss
• Failure to thrive
• Unexplained fever
• Severe diarrhoea and vomiting
• GIT bleeding
• Family history of IBD
• Chronic RIF or RUQ pain
 Examination
• Observe child while you are chatting
and taking history – behaviour,
dynamics with carers
• Abdominal examination must be
done methodically, calmly without
upsetting the child
• Be gentle / use toys to distract /
examine on parent’s lap if necessary
 Examination
• Ask child to show you with one finger the area of
maximal pain
• Ask child to protrude and then suck in their
abdomen and to cough and jump on the spot –
unable to do if peritoneal irritation existent. NO
ASSESSMENT OF REBOUND
• Palpate all quadrants
• Hernial orifices
• External genitalia
• ENT examination
• Rectal examination rarely needed
• Signs of hydration – mucous membranes /
sunken eyes / decreased skin turgor / capillary
refill time>2sec / decreased temperature /
sunken fontanelle
 Differential diagnosis
EMERGENCY/LIFE THREATENING OTHERS

• DKA - NSAP
• IBD/Crohn’s - Porphyria
• Ladd’s bands/Malrotation/volvulus - UTIs and calculi
• Appendicitis - Constipation
• Intestinal obstruction - Mesenteric adenitis
(adenoviral infection)
• Meckel’s diverticulum - Pneumonia
• Intussusception - Peptic ulcer disease
• Incarcerated inguinal hernia - Sickle cell crisis/anaemia
• Testicular torsion - Gallstones
• Trauma - Pancreatitis (choledochal cysts)
• Food/drug poisoning - Pica
• Ectopic pregnancy / ovarian torsion - Tonsillitis
- Otitis media
- Gynae pathology
- Infective enteritis
- Child abuse
- Attention seeking behaviour
 Differential diagnosis
<2 yrs 2-12 yrs 12-16 yrs

Gastroenteritis Gastroenteritis Mesenteric adenitis

Constipation Mesenteric adenitis Acute appendicitis

Intussusception Acute appendicitis Menstruation /

Mittelschmerz
Infantile colic Constipation Ovarian cyst torsion
UTI UTI UTI
Incarcerated inguinal Onset of menstruation Pregnancy / ectopic
hernia pregnancy
Trauma Psychogenic Testicular torsion
Pneumonia Trauma Psychogenic
DM Pneumonia Trauma
Volvulus DM Pneumonia
Hirschprung’s HSP DM
Sickle cell crises Constipation
NSAP Gynae pathology
 Investigations
• Laboratory studies:
- Complete blood count:
- peritonitis
- suspected perforated appendicitis
- toxic appearance
- U&Es, Creat:
- >10%dehydration
- significant history of vomiting and diarrhoea
- Amylase +/- LFTs:
- RUQ/epigastric pain
- suspected gallstones
- Blood cultures:
- Toxic child
- Temperature >103
- TFTs
- Drug levels
- ESR, CRP
- H. pylori antibodies
- RAST, Tissue transglutaminases etc
 Investigations:
• Urinalysis:
- all patients
- look for red/white cells, ketones,
glucose, metabolites
- stone analysis

• Urine culture:
- UTI if >100000 organisms/mm3

• Stool culture / O,C,P:

- if diarrhoea present
 Investigations:
• Radiological studies:

- AXR: use sparingly

- suspected pneumoperitoneum
- diffuse peritonitis
- suspected intestinal obstruction
- palpable mass
- past history of cholelithiasis/urolithiasis
- Ultrasound
- Pelvic pain (girls)
- abdominal/pelvic mass eg intussusception
- past history of cholelithiasis/urolithiasis
- testicular problems
- CT: use sparingly
- trauma
- large BMIs
- Equivocal / complicated cases

• Others:
• Laparoscopy
 Investigations
• THE MOST USEFUL TOOL IS
REGULAR ACTIVE OBSERVATION IN
THE WARD

• If sent home to the care of the

family physician or under the care of
the A&E doctor – pts need re-
evaluation after 8-12hrs if symptoms
persist
 Appendicitis
• 4 in 1000 children aged 5-14yrs yearly
• 70,000 paediatric cases per year in the
USA
• Extremely rare in neonates
• Incidence of 1-2 cases per 10,000 children
per year between birth and 4 years
• Increases to 25 cases per 10,000 children
per year between 10 and 17 years of age
 Appendicitis
• Rate of perforation is 80-100% for
children younger than 3 years vs
<10-20% of children aged 10-17
years

• Mortality rate – 0.1-1%

• M:F – 1.4:1
 Evaluation algorithms
• Kharbanda et al:
- based on 6-part scoring system: nausea (2pts), history of
focal RLQ pain (2 pts), migration of pain (1pt), difficulty walking
(1pt), rebound/percussion tenderness (2 pts), absolute neutrophil
count of >6.75x103/µl (6 pts)
- score of <5 had sensitivity of 96.3%, negative predictive
value of 95.6% and negative likelihood ration of 0.102 in the
validation set
• Samuel or Paediatric Appendicitis Score
- based on 8 variables – migration of pain to RLQ, anorexia,
nausea/vomiting, tenderness in RLQ, cough, hopping,
percussion tenderness in RLQ, elevated temperature,
leucocytosis, left shift.
- score of <5 observe ; score of >6 surgical consultation
• Alvarado or MANTRELS score
- derived from adult data
- based on 7 variables – migration of pain to RLQ, anorexia,
nausea/vomiting, tenderness in RLQ, rebound, elevated
temperature, leucocytosis, left shift
- Score>7 – sensitivity of 73% and specificity of 80%
- limited to risk stratification of suspected appendicitis in
children
 Appendicitis
• Vague central abdominal pain preceded by anorexia and
vomiting. Pain shifts and settles in right lower quadrant.
• <48hrs’ duration – if longer ?retrocaecal/pelvic appendicitis
– rectal exam diagnostic
• Mild pyrexia – high fever uncommon unless perforated
• Tachycardia
• Child reluctant to move as pain worsens
• Only 1/3 of children with appendicitis have classic
symptoms
• The appendix DOES NOT grumble – it screams or remains
silent
• Particular diagnostic problem in the extremes of age range
– in the younger child often presents late with rupture
 WCC in Appendicitis
• WCC neither sensitive nor specific for
appendicitis
• Elevated in 70-90% of pts with acute
appendicitis – also elevated in other abdo
conditions
• Predictive value limited – 10% of pts have
normal WCC
• WCC >15,000cells/mm3 – suggestive of
perforation – but Cardall et al (2004)
found no significant difference between
simple and perforated appendicitis as
regards WCC
 Ultrasound in Appendicitis
• Overall sensitivity of 85% and
specificity of 94% in experienced
hands for paediatric pts
• Noncompressible dilated appendix
• Periappendiceal abscess
• Fluid in appendiceal lumen
• Transverse diameter of 6mm or more
 Functional abdominal pain or
nonspecific abdominal pain

• 15% of school age children

• Most common symptom in childhood
worldwide
• Considerable morbidity / missed
school days / high use of health
resources
• Characterized by diagnostic
uncertainty and parental anxiety
 Definitions
• Apley and Naish 1958:
- waxes and wanes
- occurs with 3 episodes within 3 month
period
- severe enough to affect child’s activities

• Subcommittee on chronic abdominal pain,

2005:
- Chronic abdominal pain
- Longstanding intermittent or constant
abdominal pain
- functional in most children
 Definitions
• Rome III criteria, 2006:
Each of the following subtypes:
- without evidence of inflammatory,
anatomical, metabolic or neoplastic
processes to explain the pain
- all criteria fulfilled for at least 1 a wk per 2
mths before diagnosis

• Functional dyspepsia:
- persistent or recurrent pain centred upper
abdomen (above umbilicus)
- not relieved by defaecation or associated with
change in form or frequency of bowel action
 Definitions
• Irritable bowel syndrome:
- Abdominal discomfort or pain associated
for 25% of the time or more with 2 or more
of:
- improvement with defaecation
- change in frequency of stool
- change in form or appearance of stool

• Functional abdominal pain:

- Episodic or continuous abdominal pain
- Insufficient criteria for other functional GI
disorders
 Definitions
• Functional abdominal pain syndrome:
- Functional abdominal pain with one or more
of:
- some loss of daily functioning
- additional somatic symptoms
(headache, limb pain, sleep difficulty)
• Abdominal migraine:
- Paroxysmal episodes of intense periumbilical
pain lasting 1 or more hours (2 or more
times in the preceding 12mths)
- Healthy in between for weeks or months
- Pain interferes with normal activities
- Pain associated with 2 or more of:
nausea, anorexia, vomiting, headache,
photophobia, pallor
 Cause
• Multifactorial
• ?Enhanced sensitivity of the enteric
nervous system, diet and stress play
a role in causation
• Paucity of organic cause
• Biopsychosocial model proposed
• Girls>Boys
 Management
• Reassurance, supportive therapy,
education of patient and carer to prevent
abdo pain taking over lives
• Prognosis good and remits spontaneously
• Parental factors rather than psychological
characteristics of the child are more
important when predicting persistence of
abdominal pain – parents accepting
situation strongly associated with recovery
THANKYOU
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